Provider Demographics
NPI:1336495944
Name:WILLIS, JANA (MS RD LDN)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:640 CONTINENTAL DR
Mailing Address - Street 2:#48
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-6900
Mailing Address - Country:US
Mailing Address - Phone:270-901-3412
Mailing Address - Fax:270-901-3413
Practice Address - Street 1:730 FAIRVIEW AVE
Practice Address - Street 2:SUITE B1
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2367
Practice Address - Country:US
Practice Address - Phone:270-901-3412
Practice Address - Fax:270-901-3413
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered